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By U. Dennis. Loyola Marymount University.

Even areas of the dandruff subjects’ scalps with less obvious flaking still showed similar ultra- structure pathology but tape strips from the lower leg of a subject with severe dandruff were normal buy xenical 120 mg lowest price. Treatment with zinc pyrithione shampoo effected improvement in the visible dandruff which directly correlated with normalization of the stratum corneum findings buy xenical with amex. The reduced or absent desmosomes in dandruff scalp samples are in contrast to the findings in dry skin of the legs (winter xerosis) order xenical 60 mg fast delivery, where reduced degradation of corneodesmosomes and their abnormal retention in the superficial layers of xerotic stratum corneum underlie reduced desquamation (68,69). The safety, cosmetic acceptability, and ease of use are of concern since these are chronic condi- tions requiring long-term treatment. Teresi, in Lost Discoveries: the Ancient Roots of Modern Science—From the Babylonians to the Maya (70), reports that the ancient Egyptians con- cocted potions using hippopotamus fat to control dandruff. Schamberg’s A Compend of Diseases of the Skin (71) published in 1905 recommended some treatments still in use today such as salicylic acid and sulphur, but also advised that “Tonics, such as arsenic, iron, strychnin [sic], and quinin [sic] are often indicated. Efficacy Testing Methods Most clinical trials to establish efficacy of antidandruff and anti-seborrheic dermatitis products rely on direct observation of scalp scale (72–74). Typically, test subjects use a standardized non- treatment shampoo for at least two weeks to achieve a baseline state. Further standardization is achieved by specifying an interval, for instance three days, between the last wash-out shampoo use and the clinical grading. The scalp is evaluated by sectioning and parting the hair to visualize the entire scalp. The amount of observed flaking is graded visually in multiple sections of the scalp, commonly using a 0–10 or 0–4 rating scale. The evalua- tion of adherent scalp flaking is more reproducible than evaluation of loose scale, as loose flakes vary with hair texture and recent scratching, brushing or combing more than adherent scale. Scalp grading is then repeated after use of the products to be tested, commonly at inter- vals of 2, 4, and 6 weeks. While visual grading is at best semi-quantitative, a trained and experienced grader will demonstrate consistency in duplicate grading tests and reproducible results in clinical trials. Subjective data from subject questioning about pruritus or cosmetic qualities of a product may also be collected. Long-term use studies for safety and efficacy are performed with subjects using a product frequently (5–10 times per week) over weeks or months of observation. Other measures of dandruff severity such as tape stripping or counting corneocytes col- lected from scrubbing small areas of the scalp with solvents are useful for physiology studies but not practical for routine efficacy demonstration. These techniques have the inherent disad- vantage of assessing only a small portion of the scalp surface (75). Food and Drug Administration Monograph on Drug Products for the Control of Dan- druff, Seborrheic Dermatitis, and Psoriasis (77) lists the following active ingredients as “gener- ally recognized as safe and effective” for over-the-counter human use. Keratolytics Salicylic acid is still used as it was over one hundred years ago for dandruff. P&S Liquid®, a product containing mineral oil, water, glycerin, phenol, and saline that is applied to the scalp, occluded with a shower cap, and left on overnight before shampooing in the morning, can be used for scale that is difficult to remove, but is messier than simple shampooing. When using a kera- tolytic shampoo, the patient should allow the lather to stand on the scalp for a few minutes to facilitate loosening of the scale. Oils such as peanut oil or olive oil applied to the scalp under occlusion with a shower cap can soften scale and facilitate removal. Residual oily products such as pomades left on the scalp promote the growth of Malassezia and aggravate the condition. Patients should be warned against vigorous scratching since electron microscopy confirms hair shaft damage from excoriation. Antipruritics By reducing the Malassezia-driven inflammation of dandruff and seborrheic dermatitis, most effective antimicrobial shampoos are expected to also reduce scalp itch. Anti-Malassezia Agents The majority of effective treatment shampoos have in common their activity against Malassezia yeast. In general, their antidandruff effect parallels their antimicrobial potency (81–83). Coal Tar Coal tar’s antifungal effect has been demonstrated in vitro against Malassezia strains isolated from dandruff, seborrheic dermatitis, and pityriasis versicolor (84). While it is a weak antifungal, tar has additional antiproliferative (85) and anti-inflammatory effects making it a first-line choice Dandruff and Seborrheic Dermatitis: Use of Medicated Shampoos 81 for psoriatic scalp treatment. Patients with light-colored hair may notice yellow or yellowish-red staining from tar. Safety concerns regarding carcinogenicity exist since coal tar was historically recognized as a carcinogenic agent. Biopsy study of hair follicles following four days of tar shampoo use showed induction of enzyme activity critical to cancer induction (P-450-dependent aryl hydrocarbon hydroxylase) (87). After use of coal tar shampoo, urinary excretion of polycyclic aromatic hydrocarbons metabolites can be detected in humans (88). An epidemiological study in southeastern Arizona showed a slight increase over expected squamous cell skin cancers in users of tar and antidandruff sham- poos (89). Regulations in California have required labeling about possible carcinogenic risk for dermatology products containing tar. In normal use, however, tar shampoo contact with the scalp is brief, limiting safety concerns. Zinc pyrithione interferes with fungal membrane transport and inac- tivates copper-containing enzymes of bacteria and yeasts (91–93). The bioavailability rather than simply the percent present determines the efficacy. Bioavailability is influenced by active concentration, particle size, particle shape, uniformity of suspension, and delivery to the scalp. Clinical testing to date has demonstrated that an optimum particle size and shape for distribution and retention on the scalp is a thin platelet with diameter of 2. Since dandruff is a chronic condition and recolonization with Malassezia occurs readily, the long-term use of treatment shampoos is necessary. Thus, the cosmetic qualities of the sham- poo and its effect on hair texture become important compliance issues. Selenium Sulfide Selenium sulfide is also an effective antimicrobial against Malassezia (94). Selenium sulfide in micronized particles outper- forms higher concentration coarse grade products. The distinctive odor of selenium sulfide limits its acceptability to some patients. Ketoconazole Ketoconazole also has both 1% over-the-counter and 2% prescription strengths available. Both effectively eliminate Malassezia from the flake samples and improve dandruff and seborrheic 82 Hickman dermatitis with the 2% shampoo more effective than the 1% (99–101). The mechanism of action for its antifungal activity is inhibition of cell membrane ergosterol synthesis (102). Ketoconazole has also been shown to have some direct anti-inflammatory activity separate from its antimicro- bial action (103), to inhibit leukotriene biosynthesis (104) and to reduce fungal antigen-induced lymphocyte-mediated immune responses (105). Ketoconazole binds to the keratin of the hair shaft and scalp, allowing persistence of its effect between shampoos (106).

This is not an exhaustive list; healthcare settings Although it is not any more virulent than may have to produce similar lists to cover their Methicillin-sensitive Staphylococcus aureus buy generic xenical 120mg on line, needs discount xenical 60 mg visa. Strict measures the appropriate precautions specific to their route are essential where such patients are cared for buy generic xenical 60 mg on-line. Measures required to prevent cross infection with Now carry out Learning Activity 3. However, daily washing with an antiseptic is recommended, with particular attention given to commonly contaminated sites, such as the axillae and groin. Nasal carriage should be treated using mupirocin ointment three times a day for five days. Mupirocin may be applied to infected lesions (but not large Page 23 areas such as pressure sores) for up to five days. Module 1 Page 23 Infection control in special circumstances There are certain areas within healthcare settings manage, control, and investigate any outbreaks, where additional infection control measures must and provide feedback and advice to health staff. These include intensive or critical Producing and implementing local and national care units and units where immunocompromised standards and policies are also important parts of patients get nursing care (for example, transplant the team’s function. Audit of practice is essential to ensure that infection Management of patients in such units often control measures are carried out properly and requires the use of invasive devices. Health staff should be aware of the should only be used where absolutely necessary and importance of audit and always be involved. The risk of areas where audits may be useful include: infection is greatly increased in such units, due in • handwashing; part to the presence of various pieces of invasive • environmental cleanliness; equipment. All • decontamination procedures; and methods of • patient outcomes, for example, postoperative decontamination wound infections. The measures taken to prevent and control spread of number of visitors may need to be limited and infection are essential in everyday practice. Such they must be advised on the precautions to be documentation will alert healthcare workers to the followed. Thorough, correct handwashing is the recommended precautions and in turn help to most important measure that can be carried out to control nosocomial infections. Occupational health staff and infection control Other considerations staff often work closely together to provide It is recommended that infection control teams protection to staff from infectious diseases. These teams, Immunizations which should be made available consisting of an infection control doctor and include hepatitis B. In addition, occupational infection control nurse, should be consulted on all exposures to patient blood or body fluids should infection-related matters. The team should always be reported, as steps must be taken to protect regularly conduct surveillance, and audit and and reassure exposed healthcare workers. This can recommend best practice to prevent or control be done swiftly and effectively by trained nosocomial infections. Page 24 Module 1 Summary of key points The health status of the staff is clearly an important • The principles of infection control and prevention factor in limiting cross infection to susceptible are essential in the everyday care of patients within patients, particularly in high-risk areas such as healthcare settings. Illnesses (coughs and colds) as well as conditions • We continually share our environment with many (eczema and psoriasis) among healthcare staff must different microorganisms. Occupational health and infection and their pathogenicity is extremely important for control officers should work closely together when healthcare workers. More detailed information about individual diseases, including definitions, epidemiology within Europe, modes of transmission, methods of prevention, treatment options, and practical nursing care can be found in Modules 3 – 6 of this manual. A suspension of dead, attenuated, or otherwise modified microorganisms for inoculation to produce immunity to a disease by stimulation of antibodies 2. A preparation of the virus cowpox Page 41 Module 2 Page 41 Basic principles of immunization It is widely acknowledged that the two most Immunization occurs when a specific resistance to important public health interventions, which have an infectious disease is induced by the had the greatest impact on the world’s health, are administration of a vaccine. In addition, immunization has been shown to be one of the safest and most cost- Active immunization involves the stimulation of effective interventions known. This can be achieved by the Edward Jenner administration of: produced the very • live attenuated organisms: the organism’s first vaccine over two pathogenicity is reduced by sequential subculturing hundred years ago. He took some material from a cowpox • toxoid: the inactivated products of an organism pustule and scratched it into the arm of a young (for example, diphtheria, tetanus); boy. The boy developed a cowpox pustule and mild • components of organisms: such as capsular fever but remained well when subsequently polysaccharides (for example, meningococcal, inoculated with smallpox. The first vaccine had pneumococcal); and been discovered and indeed, as a consequence, the • genetically engineered viral products (for example, original meaning of “vaccine” was “protection hepatitis B). One hundred and seventy years later, following a targeted global vaccination Passive immunization does not induce an antibody programme, smallpox had been completely response; rather it involves the direct transfer of eradicated. It was to be almost one hundred years later before Immunity is gained immediately but is short-lived. A child to be prepared by taking blood from actively who had been bitten by a rabid dog was inoculated immunized donors (e. Active immunization is preferred to passive The discoveries of Jenner and Pasteur formed the immunization for the following reasons: basis for vaccine production. Now there are many • it confers long term immunity, and different types of vaccine. Page 42 Module 2 Administration of vaccines Passive immunization is generally reserved for Consent (written or implied) must be obtained situations where: from parents or guardians of small children before • rapid immunity is needed (for example, for post- any vaccine is given. It is important to understand exposure treatment of a tetanus-prone wound), and local policy on informed consent. Doctors and nurses who administer vaccines must have suitable training in the appropriate techniques. A primary course of immunization may consist of Training for anaphylaxis should be undertaken and one or more doses of vaccine depending upon the suitable drugs and equipment should be available individual vaccine. A All vaccines vary full course of immunization may consist of a slightly, but all come primary course of vaccine followed by one or more packaged with a boosters. Boosters of vaccine are given at varying manufacturer’s data intervals depending upon the individual vaccine. Vaccines needing to be reconstituted with diluent should be used within the manufacturer’s time recommendations. Generally vaccines are administered via the oral, intramuscular, subcutaneous or intradermal routes. Vaccines that are not administered via the correct route may be sub-optimal or cause harm. If the skin is cleaned with alcohol prior to the administration of a vaccine, the alcohol should be allowed to dry first. Correct vaccine administration techniques hepatitis B can be administered if appropriate. If immunization is delayed because of be disposed of safely, usually in a sharps bin for mild illness, there is a risk that the child may not incineration. Throughout the world, lost opportunity Administration of more than one vaccine because of false contraindications is a major cause When more than one live attenuated vaccine is to of delay in completing the immunization schedule. All other vaccines can be given malignant disease, therapy with immuno- within any time schedule. This is especially A severe adverse event following a dose of vaccine important in areas where vaccine uptake is poor.

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Diuretics and intrave- nous milrinone were used with improved evidence of cardiac output order xenical 60 mg with mastercard. Viral myocarditis was ruled out in view of negative inflammatory markers and negative viral titers buy 60 mg xenical otc. Endomyocardial biopsy was performed revealing nonspecific myocardial fibrosis with no evidence of inflammation buy xenical online pills. The child’s oral intake improved after few days and the child was discharged home. At the time of discharge the ventricu- lar function was slightly improved, but continued to be depressed. Case 2 History: A 2 year old was seen by the primary care physician at 5 years of age because of concern by mother that the child appeared to pass out for few seconds that same morning. Mother states that the child’s father died suddenly last year but did not know why since they were separated. The precordium was hyper- active with a prominent and slightly laterally displaced apical impulse. A harsh 3/6 systolic ejection murmur was heard over the midsternum, no diastolic murmurs were detected. Diagnosis: In view of the heart murmur, which was not previously appreciated, the child was referred for further evaluation to a pediatric cardiologist. The primary care physician was also concerned to hear of the sudden and unexplained death of the father. Chest X-ray revealed cardiomegaly and electrocardiography showed normal sinus rhythm with evidence of left ventricular hypertrophy. Treatment: The child was started on a beta blocker to reduce left ventricular out- flow obstruction and potentially minimize ventricular arrhythmias. Genetic counsel- ing of the child and his two other siblings was also sought to determine if the child or his siblings have positive genetic markers for hypertrophic cardiomyopathy. Referral to a pediatric electrophysiologist was arranged for further assessment of arrhythmias and potential need for implanted defibrillator. Bonney and Ra-id Abdulla Key Facts • An initial and crucial step in managing any child with a cardiac arrhyth- mia is to determine the hemodynamic stability of the child. A healthy pink color of skin/mucosa, brisk capillary refill, good peripheral pulses, normal blood pressure, and absence of respiratory distress are all reassuring signs that the hemodynamic status of the child is normal or near normal. Stable hemodynamics suggests that the cardiac output generated by the heart, despite the arrhythmia, is adequate. Failure to respond to medications will then require more invasive management such as pacemaker insertion in patients with bradycardia or the use of cardioversion in patients with tachyarrhythmias. Transcutaneous pacing can be performed with most bedside external defibrillators, although this maneuver is quite painful. The more commonly used medica- tions include beta-blockers, amiodarone, digoxin, and other agents. The specific type of antiarrhythmic agent, route of administration, and dose depends upon the type of arrhythmia and patient stability. These agents should be prescribed and administered under the supervision of a pediatric cardiologist. Introduction Abnormal heart rhythms, particularly those causing hemodynamic compromise, are not common in children; however, pediatricians are frequently faced with the responsibility to determine if a heart rhythm is normal in a child. Most of the time this is a straightforward issue, but sometimes because of the child’s young age and anxiety, the task becomes more challenging. Key clinical and electrocardiographic features of each arrhythmia are reviewed along with a basic management plan for each arrhythmia. It is important to remem- ber that while the arrhythmia mechanisms encountered in children are the same as those seen in adults, the incidence of various arrhythmias is quite different in the two groups. It is crucial to remember the importance of the overall con- dition of the child (i. This is the most important piece in the diagnosis and management of any arrhythmia. Children with stable hemo- dynamics can be observed or treated with oral medications. The lower limit of normal for heart rate varies with age (first year of life <100 bpm, 1–4 years <90 bpm, >5 years <60 bpm) (Fig. Causes: Factors influencing the sinus node, such as vagal stimulation, hypo- thyroidism, sedative medications, etc. In the case of symptomatic sinus bradycardia due to sinus node dysfunction with or without sinus pauses, atropine or epinephrine can be given to increase the sinus rate. Ectopic Atrial Rhythm Definition: A rhythm originating from a nonsinus source in the atrium. This can often be an escape rhythm seen when the sinus rhythm becomes very slow, or an accelerated ectopic atrial rhythm in the range of 70–90 bpm that is “outrunning” the sinus rate (Fig. Rhythms originating from low in the atrium near the coronary sinus are not uncommon. Management: Ectopic atrial rhythms are generally benign and require no treat- ment. They are often seen as escape rhythms in patients with injury to the sinus node following surgery for congenital heart disease. Wandering Atrial Pacemaker Definition: The term “wandering atrial pacemaker” is used when the rhythm is seen to oscillate between sinus rhythm and an ectopic atrial rhythm or between two ectopic atrial rhythms (Fig. Causes: Slow junctional rhythms are usually escape rhythms that are seen with slowing of the sinus node rate. Junctional rhythms that slightly exceed the sinus rate (70–90 bpm range) are referred to as “accelerated junctional rhythms. Very slow junctional rhythms (<50 bpm) may indicate sinus node dysfunction or hypervagal tone. Management: This is generally a benign finding that does not require intervention in the absence of symptoms. Management: Symptomatic bradycardia with second degree heart block is an indication for temporary or permanent pacing. In asymptomatic infants who have undergone surgery for congenital heart disease, second degree heart block is an indication for pacing. Since there is never more than one conducted beat in a row, there is no opportunity to look for gradual prolongation vs. Management: Temporary or permanent pacing is indicated in symptomatic individuals. In some instances congenital complete heart block is caused by maternal lupus, although many mothers of infants with congenital heart block have no evidence 368 W. Other acquired causes of heart block include lyme disease (first, second, or third degree heart block are possible), cardiomyopathy, and antiarrhythmic drug overdose. Management: Atropine and/or epinephrine are often effective in increasing the rate of the escape rhythm, particularly in patients who present with com- plete heart block and slow junctional rhythms. Transcutaneous pacing can be performed with most bedside external defibrillators, although this maneuver is quite painful.

The symptoms are more common in persons who have previously suffered from neurotic or personality disorders or when there is a possibility of compensation buy generic xenical 120mg on line. This syndrome is particularly associated with the closed type of head injury when signs of localized brain damage are slight or absent purchase xenical with visa, but it may also occur in other conditions discount xenical 60mg with amex. Postcontusional syndrome (encephalopathy) Post-traumatic brain syndrome, nonpsychotic Status postcommotio cerebri Excludes: frontal lobe syndrome (310. It should be used for abnormal behavior, in individuals of any age, which gives rise to social disapproval but which is not part of any other psychiatric condition. To be included, the behavior--as judged by its frequency, severity and type of associations with other symptoms--must be abnormal in its context. Disturbances of conduct are distinguished from an adjustment reaction by a longer duration and by a lack of close relationship in time and content to some stress. They differ from a personality disorder by the absence of deeply ingrained maladaptive patterns of behavior present from adolescence or earlier. Where the emotional disorder takes the form of a neurotic disorder described under 300. Overanxious reaction of childhood and adolescence Excludes: abnormal separation anxiety (309. Sibling jealousy Excludes: relationship problems associated with aggression, destruction, or other forms of conduct disturbance (312. The category of mixed disorders should only be used when there is such an admixture that this cannot be done. In early childhood the most striking symptom is disinhibited, poorly organized and poorly regulated extreme overactivity but in adolescence this may be replaced by underactivity. Impulsiveness, marked mood fluctua- tions and aggression are also common symptoms. Delays in the development of specific skills are often present and disturbed, poor relationships are common. If the hyperkinesis is symptomatic of an underlying disorder, code the underlying disorder instead. Developmental disorder of hyperkinesis Use additional code to identify any associated neurological disorder 314. Hyperkinetic conduct disorder Excludes: hyperkinesis with significant delays in specific skills (314. In each case development is related to biological maturation but it is also influenced by nonbiological factors and the coding carries no aetiological implications. Speech or language difficulties, impaired right-left differentiation, perceptuo-motor problems, and coding difficulties are frequently associated. Most commonly there is a delay in the development of normal word-sound production resulting in defects of articulation. When this occurs the coding should be made according to the skill most seriously impaired. The mixed category should be used only where the mixture of delayed skills is such that no one skill is preponderantly affected. The mental disturbance is usually mild and nonspecific and psychic factors [worry, fear, conflict, etc. In the rare instance that an overt psychiatric disorder is thought to have caused a physical condition, use a second additional code to record the psychiatric diagnosis. Where there is a specific cognitive handicap, such as in speech, the four-digit coding should be based on assessments of cognition outside the area of specific handicap. The assessment of intellectual level should be based on whatever information is available, including clinical evidence, adaptive behavior and psychometric findings. Mental retardation often involves psychiatric disturbances and may often develop as a result of some physical disease or injury. In these cases, an additional code or codes should be used to identify any associated condition, psychiatric or physical. The "late effects" include conditions specified as such, or as sequelae, which may occur at any time after the resolution of the causal condition. The category is also for use in multiple coding to identify these types of hemiplegia resulting from any cause. The category is also for use in multiple coding to identify these conditions resulting from any cause. The "late effects" include conditions specified as such, as sequelae, or present one year or more after the onset of the causal condition. Signs and symptoms that point rather definitely to a given diagnosis are assigned to some category in the preceding part of the classification. In general, categories 780-796 include the more ill-defined conditions and symptoms that point with perhaps equal suspicion to two or more diseases or to two or more systems of the body, and without the necessary study of the case to make a final diagnosis. Practically all categories in this group could be designated as "not otherwise specified," or as "unknown etiology," or as "transient. Where a code from this section is applicable, it is intended that it shall be used in addition to a code from one of the main chapters of the International Classification of Diseases, Injuries and Causes of Death, indicating the nature of the condition. Machinery accidents [other than connected with transport] are classifiable to category E919, in which the fourth digit allows a broad classification of the type of machinery involved. If a more detailed classification of type of machinery is required, it is suggested that the "Classification of Industrial Accidents according to Agency," prepared by the International Labor Office, be used in addition. Categories for "late effects" of accidents and other external causes are to be found at E929, E959, E969, E977, E989, and E999. Definitions and examples related to transport accidents (a) A transport accident (E800-E848) is any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another. Includes: accidents involving: aircraft and spacecraft (E840-E848) watercraft (E830-E838) motor vehicle (E810-E825) railway (E800-E807) other road vehicles (E826-E829) In classifying accidents which involve more than one kind of transport, the above order of precedence of transport accidents should be used. Vehicles which can travel on land or water, such as hovercraft and other amphibious vehicles, are regarded as watercraft when on the water, as motor vehicles when on the highway, and as off-road motor vehicles when on land, but off the highway. Excludes: accidents: in sports which involve the use of transport but where the transport vehicle itself is not involved in the accident involving vehicles which are part of industrial equipment used entirely on industrial premises occurring during transportation but unrelated to the hazards associated with the means of transportation [e. Excludes: accidents: in repair shops in roundhouse or on turntable on railway premises but not involving a train or other railway vehicle (c) A railway train or railway vehicle is any device with or without cars coupled to it, designed for traffic on a railway. It is defined as a motor vehicle traffic accident or as a motor vehicle nontraffic accident according to whether the accident occurs on a public highway or elsewhere. Excludes: injury or damage due to cataclysm injury or damage while a motor vehicle, not under its own power, is being loaded on, or unloaded from, another conveyance (f) A motor vehicle traffic accident is any motor vehicle accident occurring on a public highway [i. A motor vehicle accident is assumed to have occurred on the highway unless another place is specified, except in the case of accidents involving only off-road motor vehicles, which are classified as nontraffic accidents unless the contrary is stated. A roadway is that part of the public highway designed, improved and ordinarily used, for vehicular travel. Includes: approaches (public) to: docks public building station Excludes: driveway (private) roads in: parking lot industrial premises ramp mine roads in: private grounds airfield quarry farm (i) A motor vehicle is any mechanically or electrically powered device, not operated on rails, upon which any person or property may be transported or drawn upon a highway.

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